868 Auto Center Drive / Ste A • Palmdale, CA 93551 Phone
(661) 208-4280
• Fax
(661) 208-4287
Avnew.ddsmarketing.io
Referral Date:
Office Phone:
Patient Name:
Referring Doctor:
Patient Phone:
Extractions#
TMJ
Pathology
Expose and Bond Ortho Bracket
Other
Additional Remarks:
1
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8
9
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32
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30
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A
B
C
D
E
F
G
H
I
J
T
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R
Q
P
O
N
M
L
K
Periodontal Disease
Gingival Recession #
Crown Lengthening #
Frenectomy
Other
Extractions / Socket Graft #
Pathology
Implant Evaluation For:
Teeth #:
Please place stock abutment(s)
Referring dentist will place abutment
Has the patient received quadrant scaling and root planing?
YES
NO
DATE:
X-RAYS:
Does the patient have a recent FMX you can provide us?
YES
NO
DATE:
Your Restorative Plans Or Comments:
